The Effect of Single-Dose Bupivacaine on Postoperative Iliac Crest Graft Donor Site Pain.

BACKGROUND: Postoperative donor site pain remains a major source of morbidity following iliac crest bone graft harvesting (ICBGH). AIM: The aim of this study was to investigate the effect of single-dose infiltration of bupivacaine on donor site pain following ICBGH. SUBJECTS AND METHODS: This study was a double-blind randomized controlled trial of 30 adult individuals that required an ICBG as part of the treatment for mandibular reconstruction. Individuals were divided into two groups, to receive a single-dose subcutaneous infiltration of either 0.25% bupivacaine or 0.9% normal saline at the iliac crest graft incision site following ICBGH. Length of incision at the ICBGH site, dimensions of harvested graft, time taken for the iliac crest harvest surgery, total daily dose of postoperative analgesics, pain from the ICBGH site as well as gait disturbance were recorded. Data were analyzed using SPSS version 17.0, and P < 0.05 was considered statistically significant. RESULTS: There was a progressive decrease in pain score from the 1st to the 4th postoperative day, with no significant difference between the two groups. There was no statistical difference between the two groups in terms of dynamic median pain score at the early postoperative period as well as at the 4th and 12th week postoperative period. The analgesic consumption between the two groups also did not show any significant difference. CONCLUSION: Local injection of single dose of 0.25% bupivacaine did not offer additional benefit in the management of postoperative iliac crest donor site pain following ICBGH.

Open-heart surgery programme in Nigeria: The good, the bad and the ugly.

The development of open-heart surgery (OHS) programme in Nigeria has followed the different economic phases. Starting from the oil boom era in the 70s to 80s when indigenous efforts led to the successful performance of the first set of OHS to the period of depressed economy in the 80s to 90s that witnessed a lull in the programme, the revamping of the programme that started in the mid-90s following intense collaboration with foreign groups is gradually being sustained. The aim of this article was to examine the current efforts at sustaining the development of OHS programme in Nigeria with a view to identifying various challenges and how such can be addressed.

Randomized Controlled Trial comparing Dressing and No Dressing of Surgical Wound after Cleft Lip Repair.

BACKGROUND: Cover wound dressings are regarded as important postoperative care following surgical intervention. Opinions differ on whether the cleft lip repair wound should be routinely covered by dressings or not. Therefore, a well designed randomized controlled trial is required to determine if routine cover dressing offers a better outcome. AIM: The aim of this study was to compare the outcome of wound and cosmetic appearance of cleft lip repair in a randomized controlled trial between cover wound and no wound dressing groups. MATERIALS AND METHODS: Forty consecutive patients requiring cleft lip repair were randomized prospectively to receive the traditional wound dressing cover (n = 20) or had the wound left exposed without any dressing cover (n = 20), after the completion of cleft wound closure. The main outcome measures were wound infection and dehiscence rates in the two groups, in addition to the scar cosmetic outcomes. RESULT: The two groups were comparable in terms of age and sex. The incidence of wound infection was 0% (0/20) in cover dressing group as compared to 5% (1/20) in no cover dressing group (p = 0.31). No statistical significant differences in the wound dehiscence rate between the wounds that received dressing (15%) and those with no dressing (20%) were observed. The mean diameter of scar at the 5th to 8th week review appointments was almost similar between the group with dressing (3.29 ± 1.26 mm) and no dressing (3.62 ± 1.28 mm). The patient reported outcome in relation to the cosmetic appearance of the scar after repair was similar in the two groups. CONCLUSION: There was no difference in the main outcome measures between the group that had cover dressing and those with exposed wound after cleft lip repair surgery. This study demonstrates that dressing of cleft repair wound may be unnecessary.

Hemodynamic monitoring in Nigerian patients undergoing high-risk surgery.

BACKGROUND: Hemodynamic monitoring (HM) and optimization of cardiac output and parameters of dynamic fluid responsiveness is said to improve perioperative outcome in high-risk surgical patients (HRSP). There is insufficient data to determine the burden of care and HM practices in HRSP in Nigeria. Hence, the need to assess and document the current hemodynamic management practices of anesthetists in Nigeria regarding patients undergoing high-risk surgery. METHODS: An electronic mail (E-mail) based survey was conducted among 180 consultant members of the Nigeria Society of Anaesthetists. The survey contained 24 questions that range from practice location, experience in the perioperative management of high-risk patients, expectations of care, to what is available to the anesthetists to provide such care. The survey was on for 3 months. RESULTS: A total of 157 E-mail messages were delivered, and 73 responses were received, giving a response rate of 46.5%. The survey showed that 67 (91.8%) of respondents provide or directly supervise anesthesia for HRSP, 50 (84%) of them do this 1-5 times a week. Noninvasive blood pressure (83.6%) was routinely monitored while the central venous pressure (CVP 35.6%), invasive blood pressure (28.8%), and cardiac output (1.4%) monitored less often. Urine output, arterial blood pressure, pulse rate, and clinical experience were considered best indicators of volume expansion. Most respondents were of the opinion that oxygen delivery to tissues is of major importance during the management of HRSP. CONCLUSION: Nigerian consultant anesthetists employ mostly noninvasive blood pressure, CVP, and invasive blood pressure for HM in HRSP. Though a good knowledge of hemodynamic goals was demonstrated, most rated their practice as inadequate.

Intra-Operative Airway Management in Patients with Maxillofacial Trauma having Reduction and Immobilization of Facial Fractures.

BACKGROUND: Despite advancements in airway management, treatment of fractures in the maxillofacial region under general anesthesia remains a unique anesthetic challenge. We reviewed the pattern of airway management in patients with maxillofacial fractures and assessed those challenges associated with the different airway management techniques employed. MATERIALS AND METHODS: The anesthetic chart, theatre and maxillofacial operations records of patients who had reduction and immobilization of various maxillofacial fractures over a 2-year period were reviewed. Information obtained included the patient demographics, mechanisms of injury, types of fractures and details about airway management. Statistical Package for Social Sciences, SPSS version 17.0 was utilized for all data analysis. RESULTS: Fifty-one patients were recruited during the 2-year study period. Mask ventilation was easy in 80-90% of the patients, 80% had Mallampati three or four, while 4 (7.8%) had laryngoscopy grading of 4. There was no statistically significant difference between the fracture groups in terms of the laryngoscopy grading (P = 0.153) but there was statistical significant difference in the technique of airway management (P = 0.0001). Nasal intubation following direct laryngoscopy was employed in 64.7% of the patients, fiber-optic guided nasal intubation was utilized in only 7.8%. None of the patients had tracheostomy either before or during operative management. CONCLUSION: Laryngoscopic grading and not adequacy of mouth opening predicted difficult intubation in this group of patients in the immediate preoperative period. Despite the distortions in the anatomy of the upper airway that may result from maxillofacial fractures, nasal intubation following direct laryngoscopy may be possible in many patients with maxillofacial fractures.

Prolonged intensive care unit stay after coronary artery bypass graft surgery: Role of perioperative factors.

INTRODUCTION: Long stay in the Intensive Care Unit (ICU) after coronary artery bypass graft (CABG) surgery has been found to result in increased hospital mortality, poor long-term prognosis, prolonged hospital stay, and consequently, high cost and expenses. We, therefore, reviewed CABG surgery performed at the Madras Medical Mission Chennai, India, during a 3-month period to determine perioperative factors that are significant predictors of prolonged ICU admission. METHODS: We retrospectively studied patients who had elective CABG surgery from November 2008 to January 2009. Information about the following perioperative variables were retrieved; patient demographics, history of co-morbid disease, pre-operative left ventricular (LV) function, the number of coronary vessels grafted, duration of bypass, the level of cardiovascular support post-bypass, the need for surgical re-exploration and duration of stay in the ICU. Prolonged ICU admission was defined as stay over 4 days after elective CABG surgery. RESULTS: A total of 194 patients were reviewed, with males accounting for 84%, age ranged from 32 to 80 years, and duration of stay in the ICU from 2 to 14 days, with mean values of 58.06 ± 8.48 years and 3.96 ± 1.60 days, respectively. Univariate analysis showed significant differences in the number of patients with pulmonary hypertension (P = 0.002), mean bypass time (P = 0.018), requirement for LV support with inotrope (P = 0.021) and surgical re-exploration (P = 0.016) when patients with ICU stay ≤4 days were compared to those with stay over 4 days. Multiple regression revealed only LV support (ß =0.69; P = 0.003) as the independent predictor of prolonged ICU stay. CONCLUSION: This review showed LV support with inotrope as the only independent predictor of prolonged ICU stay after CABG surgery. Therefore, an excellent perioperative care leading to a reduced requirement for LV support after cardiopulmonary bypass for CABG surgery should be the goal.